Correspondence

Antiretroviral Therapy in Patients with Dual Infection with Human Immunodeficiency Virus Types 1 and 2

N Engl J Med 2000; 342:1758-1760June 8, 2000

Article

To the Editor:

The number of patients with human immunodeficiency virus type 2 (HIV-2) infection in western Europe is increasing; at our hospital we currently follow 630 patients seropositive for human immunodeficiency virus type 1 (HIV-1), 14 seropositive for HIV-2, and 6 with seropositivity for both HIV-1 and HIV-2. All the HIV-2–seropositive patients belong to or have direct links with a group of West African immigrants residing in the Rotterdam area. Six previously untreated HIV-2–seropositive patients who were given 300 mg of zidovudine twice daily, 150 mg of lamivudine twice daily, and 800 mg of indinavir three times daily have improved clinically, with a decrease in plasma HIV-2 RNA levels to less than 500 copies per milliliter (data not shown). Here we describe the failure of antiretroviral therapy in two previously untreated patients with both HIV-1 and HIV-2 infection.

One patient was an asymptomatic 55-year-old Cape Verdean man. At base line, his CD4+ cell count was 50 per cubic millimeter, and his plasma HIV-1 RNA level (measured with Cobas Amplicor 1.5, Roche Diagnostics) was 7500 copies per milliliter. He was treated with 400 mg of ritonavir twice daily and 400 mg of saquinavir twice daily. His plasma HIV-1 RNA level was undetectable (<500 copies per milliliter) within 4 weeks and has remained undetectable for 18 months. The second patient was an asymptomatic 28-year-old man from the Ivory Coast. At base line, his CD4+ cell count was 40 per cubic millimeter, and his plasma HIV-1 RNA level was 5400 copies per milliliter. He was treated with 300 mg of zidovudine twice daily, 150 mg of lamivudine twice daily, and 1250 mg of nelfinavir twice daily. His plasma HIV-1 RNA level decreased to fewer than 500 copies per milliliter within four weeks and has remained undetectable for nine months. In both patients, the reduction in plasma HIV-1 RNA levels suggested adequate viral suppression. However, retrospective analyses of plasma HIV-2 RNA levels revealed no decrease in the first patient (47,000 HIV-2 RNA copies per milliliter at the last visit) and an initial decrease from 2700 copies per milliliter to an undetectable level (<500 copies per milliliter), followed by a rebound to 48,000 copies per milliliter, in the second patient (Figure 1Figure 1Plasma HIV-1 and HIV-2 RNA Levels and CD4+ Cell Counts before and during Antiretroviral Therapy in Two Patients with HIV-1 and HIV-2 Infection.).

HIV-2 is thought to have a protective effect against HIV-1 superinfection, so that in dually infected patients either HIV-1 or HIV-2, but not both, actively replicates.1 In these two patients, however, both HIV-1 and HIV-2 actively replicated before the initiation of therapy. Given the different susceptibilities of HIV-2 strains to protease inhibitors and the more limited options for the treatment of HIV-2 infection,2,3 we recommend caution before the initiation of antiretroviral therapy in patients with both HIV-1 and HIV-2 infection. The therapy chosen for the two patients described here led to no change or an increase in plasma HIV-2 RNA levels. This outcome may be expected to result in progression toward end-stage HIV-2 disease. In the case of dual infection, antiviral drugs known to be active against both viruses should be given,3 and both plasma HIV-1 and HIV-2 RNA levels should be measured periodically.

Martin Schutten, Ph.D.
Marchina E. van der Ende, M.D.
Albert D.M.E. Osterhaus, D.V.M., Ph.D.
Erasmus Medical Center Rotterdam, 3015 GD Rotterdam, the Netherlands

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   Julia Drylewicz, Serge Eholie, Moussa Maiga, Djimon Marcel Zannou, Papa Salif Sow, Didier K Ekouevi, Kevin Peterson, Emmanuel Bissagnene, François Dabis, Rodolphe Thiébaut. (2010) First-year lymphocyte T CD4+ response to antiretroviral therapy according to the HIV type in the IeDEA West Africa collaboration. AIDS 24:7, 1043-1050
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   Marie-Yolande Borget, Karidia Diallo, Christiane Adje-Toure, Terence Chorba, John N. Nkengasong. (2009) Virologic and immunologic responses to antiretroviral therapy among HIV-1 and HIV-2 dually infected patients: Case reports from Abidjan, Côte d’Ivoire. Journal of Clinical Virology 45:1, 72-75
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